Every finding on record at Westminster Health & Rehab Center

Based on observation, interview, and facility policy review, the facility failed to ensure raw meat was stored properly in the walk-in refrigerator. This deficient practice had the potential to affect all 6 residents who currently resided in the facility.Findings included:Review of the facility policy titled, Food and Supply Storage, revised 01/2026, indicated, Separate cooked and raw foods. Store ready-to-eat (including pasteurized eggs) and cooked food above raw food. If raw animal foods are stored on the same rack, store them in the following order from top of the rack to the bottom of the rack: raw shell eggs, fish, whole cuts of beef, pork, ground meat and poultry.During a concurrent interview and observation of the walk-in refrigerator in the kitchen on 02/23/26 at 10:28 AM with the Administrator and Clinical Dietician, there were three boneless pork tenderloins located on the second shelf above a covered bowl of coleslaw and a covered bowl of fruit cocktail. Also, there was 15 pounds of raw bacon above some tomatoes. The Clinical Dietician stated the raw pork tenderloin should not have been stored above the coleslaw and fruit cocktail and the raw bacon should not have been stored above the tomatoes because it could cause contamination to the residents if the raw meat dripped.During an interview on 02/25/26 at 2:23 PM, the Director of Nursing stated she expected raw meat to be stored properly.During an interview on 02/25/26 at 2:56 PM, the Administrator stated he expected food to be stored consistent with regulatory practices that governed the kitchen.

Based on interview, record review, and facility policy review, the facility failed to ensure transfer and discharge notifications were sent to a representative of the State Long Term Care (LTC) Ombudsman for 2 (Resident (R)6 and R8) of 2 sampled closed records reviewed. Findings included: A facility policy titled, Transfer or Discharge Notices, revised 03/2025, indicated, 3. The facility will send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman. 4. Notice of the State LTC Ombudsman will occur at the same time as the notice of discharge is provided to the resident and resident representative. 1. A Resident Face Sheet revealed the facility admitted R8 on 11/06/25. According to the Resident Face Sheet, the resident discharged home on [DATE]. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/15/25, revealed R8 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated there was an active discharge plan in place for the resident to return to the community. R8's Care Plan included a problem statement edited 12/16/25, that indicated the resident was to receive a comfortable transition home after the completion of the respite/LTC stay. Interventions directed staff to confer with all disciplines to ensure the discharge was safe and secure (initiated 11/12/25). R8's Transfer/Discharge Notice dated 01/06/26, indicated the resident discharged home. 2. A Resident Face Sheet indicated the facility admitted R6 on 12/24/25. According to the Resident Face Sheet, the resident discharged to a local hospital on [DATE]. R6's Transfer/Discharge Notice dated 12/30/25 indicated the resident had a change in medical condition and was transferred/discharged to the hospital. During an interview on 02/24/26 at 2:55 PM, the Director of Social Services (DSS) stated she was not providing a representative of the Office of the State LTC Ombudsman with resident discharge notices, but she was responsible for providing the Ombudsman with the notification. The DSS stated she had not sent R6's or R8's discharge notice to a representative of the Office of the State LTC Ombudsman. During a telephone interview on 02/25/26 at 12:56 PM, the Ombudsman stated she had not received a resident discharge notice from the facility since 05/25. During an interview on 02/25/26 at 2:20 PM, the Director of Nursing (DON) stated if the requirement was to send discharge notifications to the Ombudsman, then that was what they should do. The DON stated she was not aware the facility was not sending the notices to the Ombudsman. During an interview on 02/25/26 at 3:03 PM, the Administrator stated the facility would comply with the requirement.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure their medication error rate was not greater than 5 percent (%). There were 2 errors out of 29 opportunities, which resulted in a medication error rate of 6.9% for 2 (Resident (R)9 and R11) of 3 residents observed for medication administration. Findings included:A facility policy titled, Administering Medications, revised 04/2019, indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame.1. A Resident Face Sheet indicated the facility admitted R9 on 12/01/25. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of allergic rhinitis.R9's Physician Order Report, for the timeframe 01/25/26 - 02/25/26, revealed an order dated 11/18/25, for Flonase allergy relief 50 micrograms (mcg) per actuation (spray), administer two sprays to each nostril once a day.During medication administration observation on 02/23/2026 at 3:34 PM, Registered Nurse (RN)1 prepared and administered R9's medications. RN1 administered Flonase allergy relief 50 mcg/spray to R9; however, she administered only one spray to each of the resident's nostril. Prior to exiting R9's room on 02/23/2026 at 4:00 PM, RN1 confirmed she administered one spray to each nostril for the Flonase nasal spray.During an interview on 02/24/26 at 3:56 PM, RN1 stated R9 was administered one spray of Flonase to each nostril. RN1 reviewed R9's physician orders and stated the physician order was for two sprays to each nostril. RN1 stated she should have administered two sprays of Flonase to each of the resident's nostrils.2. A Resident Face Sheet indicated the facility admitted R11 on 02/20/26. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of osteoporosis.R11's Physician Order Report, for the timeframe 01/25/26 - 02/25/26, revealed an order dated 02/21/26, for cholecalciferol 125 micrograms (mcg), give one capsule by mouth daily for supplement.During medication administration observation on 02/24/26 at 8:38 AM, Licensed Practical Nurse (LPN)2 administered one 25 mcg one tablet of cholecalciferol to R11 instead of the ordered dose of 125 mcg.During an interview on 02/24/26 at 11:56 AM, LPN2 provided and observed the bottle of cholecalciferol that was used for R11's medication administration. LPN2 confirmed the cholecalciferol bottle was 25 mcg and was what he administered. LPN2 reviewed R11's physician orders and stated the order was for 125 mcg, and he only gave one tablet.During an interview on 02/25/26 at 2:28 PM, the Director of Nursing (DON) stated she expected for the nurse to follow the physician orders and check the five rights of medication administration. The DON stated she expected the medication error rate to be less than 5%. The DON stated both residents should have received the correct dose of medication.During an interview on 02/25/26 at 2:55 PM, the Administrator stated his expectation was that all medications would be administered according to physician orders.

Based on review of facility policy, observation and interview, the facility failed to ensure an excessive amount of lint was removed from 2 of 2 clothes dryers. The lint was noted above and behind the lint basket and on the 3 inside walls of the clothes dryers. Findings include: Review of a facility document titled, Laundry Assistant/ Equipment and Supply Functions states, . clean the lint screen for each commercial dryer at a minimum of each shift and when necessary. During an observation on 03/19/25 at 12:13 PM, of two dryers revealed the lint baskets and three walls below the dryers contained an excessive amount of lint. During an observation on 03/19/25 at 12:20 PM, the signage posted on 1 of 2 dryers stated, Clean Lint Filters, Remove Lint from the Dryer Lint Screens Every Time You Use the Dryer. This Helps Prevent A Fire, But It Also Helps Laundry To Dry Faster. During an interview and observation on 03/19/25 at 12:33 PM, the Environmental Services Supervisor (ESS) confirmed the excessive amount of lint. The ESS stated that the laundry staff removes the lint from the lint baskets daily. He also stated there is a re-occurring work order for cleaning logs using an APP called IAM CARE and is signed off on when cleaned. During an interview on 03/19/25 at 1:30 PM, the Laundry Assistant confirmed laundry does not use a lint log. The Laundry Assistant went on to say she cleans the lint basket after each dryer load but does not clean the 3 walls under the dryer. During an interview on 03/19/25 at 1:47 PM, the Building Operations Manager reported he was told about the condition of the dryer baskets and under the dryers. The Building Operations Manager further stated, that's uncalled for and the Environmental Services Supervisor will ensure excessive lint does not occur again. During an interview on 03/20/25 at an unspecified time, the Infection Preventionist revealed the facility does not have a laundry policy for maintenance of laundry equipment. During an interview on 03/20/25 at 12:30 PM, the Janitor revealed he cleans the dryer lint baskets, under dryer controls, and the area behind the dryers using a wet/dry vacuum. The Janitor stated he did not know he needed to clean behind the lint basket, the 3 walls and under the dryer until it was pointed out to him on yesterday. The Janitor concluded he had not been trained or educated about cleaning under the dryer and the 3 walls of dryer and was surprised about the excessive amount of lint.

Based on observation, record review, and interview, the facility failed to prevent potential accidents related to over the counter (OTC) medication's being at bedside for Resident (R)1, for one of one resident reviewed for accidents hazards. Findings include: Review of the facility's policy titled, Medication Administration Record copyrighted 2001, revealed, Medications are administered in a safe and timely manner, and as prescribed . Policy Interpretation and Implementation . 24. Topical medications used in treatments are recorded on the resident's treatment record (TAR) . 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safety. Review of the facility's policy titled, Self-Administration of Medications version 09/2020, revealed, The facility shall permit residents who are competent and physically able to self-administer their medications if the following conditions are met: 1. Self-administration of medications by residents is permitted only on the specific written orders of the resident's physician or other legally authorized prescriber and documented in the resident's medical record. 2. Specific instructions for administration of prescription medications are printed on the medication label. Procedure: 1. Residents who requested approval to self-administer shall be assessed by the interdisciplinary team to determine if the resident is competent. 2. The interdisciplinary team will assess the resident's cognitive, physical, and visual ability to carry out this responsibility. Facility staff may use the medication self-administration for (Form #161) or a facility-developed mechanism to document this assessment. If the team determines that the resident is competent, the attending physician shall be contacted to request a specific order for self-administration of the medication. 5. Medications stored at bedside shall be secure from other residents. The medications provided to the residents for bedside storage are kept in the containers dispensed by the provider pharmacy. Sleft [sic] administration of medications by residents is verified by direct contact with the resident by a licensed nurse and recorded on the MAR by the same person. Verification and documentation shall occur at the same frequency as the medication is taken. The MAR will reflect self-administration orders and will be addressed in the care plan. Facilities may elect to prohibit self-administration. The facility shall not allow residents to self-administer controlled substances. Review of R1's Face Sheet revealed the facility admitted (R)1 on 02/18/25, with diagnoses including but not limited to: fracture unspecified part of neck of right femur, subsequent for closed fracture with routine healing, unspecified, and need for assistance with personal care. Review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date of 02/25/25, revealed R1's Brief Interview for Mental Status (BIMS) score of 13 out 15, indicated R1 had moderate cognitive impairment. Review of (R)1's Care Plan did not reveal a Care Plan related to R1 self-administering medications. Review of (R)1's Orders and Treatment Record for the month of March 2025, did not reveal an order for self-administration of ultra strength pain reliever cream. During an observation on 03/18/25 at 1:45 PM, on top of R1's bed side table there was an ultra strength pain reliever cream. During an interview on 03/20/25 at 2:19 PM, the Director of Nursing (DON) stated, They should not have over the counter creams in their rooms. I have asked the staff if they see medications at the bedside to remove it and report it to their nurse. The certified nursing assistants (CNAs) should let the nurse know if they discover creams or any outside medications at the bedside. If it is something we can order, we will call the physician and get an order. During an interview on 03/20/25 at 2:40 PM, the DON stated, We tell the families not to bring in over the counter medications or creams, but they continue to bring those items in without notifying us. During an observation on 03/20/25 at 2:42 PM, R1's daughter was getting off the elevator on the 200 Unit. R1's daughter had a bag containing cough drops, one Ensure, and other items that were not identified. R1's daughter spoke to the nurses sitting at the nurse's desk while passing by and proceeded to the resident room. The daughter did not let the nurses know what she was bringing for R1. During an interview on 03/20/25 at 2:46 PM, R1's daughter stated, I usually bring in items the she (R1) used while she was in assisted living. The cream that was at her bedside is like Voltaren cream for her knee. The physician stated she could have that cream.

Based on review of facility policy, observation and interview, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance to professional standards including expiration dates, for 1 of 1 treatment cart. Findings include: Review of the facility's policy titled Medication Storage (SC SNF Pharmacy Policy and Procedure Manual), version 09/2020, did not reveal information on professional standards of on labeling, expiration dates, or discarding expired medications. During an observation on 03/18/25 at 12:46 PM, the treatment cart revealed the following: One Hydrofera Blue 10.2cm x 10.2 cm 4x4 Sterile, Ref# HB4414, Lot # 190328150, exp 02/01/2024. Aloe cream, LOT #313, Manufacturer Rugby Laboratories, expired 11/24. Two sterile suture removal kits, Manufacturer Dynamex Corporation, Lot #51842, expired 01/04/2025. Thirty sterile wood shaft cotton tipped applicators, Ref #76800, Manufacturer ProAdvantage by NDC, Lot #91504, expired 02/2024. The expired medications was verified and removed by Registered Nurse (RN)1. During an interview on 03/18/25 at 12:53 PM, RN1 stated, The nurses review the wound cart once a week. The night nurse check for expirations on the treatment cart daily. The pharmacy comes every month to check for expiration dates. During an interview on 03/20/25 at 8:35 AM, the Director of Nursing (DON) stated, I will get with our staff members who handle supplies and redo an education session.

Based on review of facility policy, interview and record review, the facility failed to accurately notify the physician of all pertinent information with regards to a significant medication error. Specifically, on [DATE], the facility reported to the Medical Director that Resident (R)1 received twice the dosage of insulin when R1 actually received ten times the dosage of insulin. Furthermore, the facility failed to notify the Medical Director of changes in blood sugar for a two-hour period. On [DATE] at approximately 3:00 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On [DATE] at 6:15 PM, the facility was notified that the failure to accurately notify the physician that Resident (R)1 received 80 units of insulin and the failure to continuously notify the physician of R1's blood sugars after the medication error constituted Immediate Jeopardy (IJ) at F580. The survey team provided the facility with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.10 - Resident Rights. On [DATE] at 10:55 AM, the facility presented an acceptable plan of removal of the IJ. On [DATE] at 12:00 PM, the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F580 at a lower scope and severity of D. Findings include: Review of the facility's undated policy titled Acute Condition Changes - Clinical Protocol documented, Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Type 2 diabetes mellitus, malignant neoplasm of head of pancreas, hepatic encephalopathy, and moderate protein-calorie malnutrition. Review of R1's Physician Orders revealed an [DATE] order for Insulin Aspart 100 units/mL qid (four times a day) - before meals and at bedtime. Cover with sliding scale. Give 2 units for ,d+[DATE] mg/dL (milligrams per deciliter). Give 4 units for 201 - 250 mg/dL. Give 6 units for ,d+[DATE] mg/dL. Give 8 units for ,d+[DATE] mg/dL. Give 10 units for 351 mg-400 mg/dL. During an interview on [DATE] at 11:46 AM, Registered Nurse (RN)1 revealed R1 was ordered for 8 units of short acting insulin but received 80. RN1 further stated, Licensed Practical Nurse (LPN)1 used the tuberculin syringe instead of the insulin syringe to calculate the dosage, believing the calibrations to be the same. The resident ate breakfast but not lunch and supper, so the doctor ordered to send the patient out to the hospital. Review of LPN1's statement to the facility, written on [DATE], revealed she took R1's blood sugar at 1:15 PM, which was 343 mg/dL. According to his order, he required 8 units of insulin. She administered the insulin at 1:19 PM. At 1:59 PM she realized she had made a medication error and contacted the Director of Nursing (DON). The DON notified the doctor who ordered blood sugar checks every 30 minutes. If blood sugar is < 80, contact the doctor and administer Glucagon HCl 1 mg/mL. At 2:15 PM the resident's blood sugar was 315 mg/dL. At 2:30 PM, R1 consumed 4 oz of ginger ale. At 3:00 PM, R1's blood sugar was 275 mg/dL. At 4:43 PM, the resident's blood sugar was 163 mg/dL. At 4:45 PM, LPN1 reported the verbal order from the physician to LPN2 during shift change. That evening, around 6:45 PM, LPN1 returned to the facility to finish clerical work. LPN2 informed her she had not taken R1's blood sugars during her shift since it was not in the system. LPN1 took R1's blood sugar which was 49 mg/dL. She notified the physician and injected Glucagon 1 mg/mL. During an interview on [DATE] at 1:34 PM, LPN1 confirmed she administered insulin at 1:19 PM on [DATE] and realized the mistake at 1:59 PM. LPN1 stated she used a tuberculin syringe, not realizing it scaled differently than the insulin syringes. LPN1 stated she realized the mistake at 1:59 PM and notified the Director of Nursing (DON), who notified the physician. The physician gave the verbal order to check blood sugars every 30 minutes and contact her if the blood sugar reached 80 mg/dL and inject Glucagon. LPN1 documented blood sugars on paper and on the Electronic Medical Record (EMR). LPN1 further stated she left her shift at 4:45 PM and relayed the verbal order to the oncoming nurse (LPN2). LPN1 stated she returned to the facility at 6:45 PM and learned that LPN2 had not taken any fingerstick blood sugars in that 2-hour lapse. LPN1 stated she took the blood sugar of R1 and it was 49 mg/dL. LPN1 administered the glucagon. This was the first time that glucagon was administered to R1. During an interview on [DATE] at an unspecified time, the Medical Director (MD) revealed she was contacted by the facility at 2:00 PM on [DATE]. At that time, she was told R1 was given twice the amount of insulin ordered and his blood sugars had been in the 400s prior to administration. The MD stated she was told R1 ate a full lunch and was eating dinner. She did not get phone calls from approximately 5:00 PM to 7:00 PM. The MD further stated at around 7:00 PM she was informed his blood sugar was 90 mg/dL and she instructed the facility to administer glucagon. The MD stated she did not get another call for another few hours when R1's blood sugar dropped to the 70s. The MD had R1 sent out to the hospital. The next day the report was inconsistent with what the MD had been told. R1 had received 80 units of insulin instead of 8 units, and the resident did not eat a full lunch. The MD concluded, had she known this at the time it would have affected her medical decision making. The MD stated she would have ordered R1 to be sent out to the ER immediately rather than conduct 30-minute blood sugar checks. Review of the DON's statement to the facility written on [DATE] at 6:55 PM, revealed that at 2:00 PM she received a text message from LPN1. LPN1 was at the medication cart and informed the DON that R1 had received an overdose of insulin. The DON called the Medical Director who gave telephone orders to check blood sugars every 30 minutes, notify the Medical Director with results, and administer Glucagon HCL 1 mg/mL if blood sugars are below 80 mg/dL. At 3:00 PM, R1's blood sugar was 275 mg/dL. At 4:43 PM his blood sugar was 163 mg/dL. At 6:45 PM, his blood sugar was 49 mg/dL and LPN1 administered the glucagon and notified the physician. The DON instructed LPN1 how to obtain another glucagon emergency kit in case it became necessary to administer a second dose. The Medical Director gave new orders to hold all insulin and check R1's blood sugar in another hour and inform her with results. LPN1 informed LPN2 of the new orders. LPN1 later called the DON to say another glucagon was administered and the Medical Director had been notified. The Medical Director gave new orders to check R1's blood sugars at 11:00 PM and twice during the night. At 11:42 PM, the DON contacted LPN2 for the 11:00 PM blood sugar results - which was 89 mg/dL. The Medical Director was contacted and advised to give R1 orange juice. At 1:50 AM, the DON called LPN2 and she informed the DON that R1 had been sent out to the emergency room . During an interview on [DATE] at 2:30 PM, the DON revealed she was informed of the medication error at 2:00 PM on [DATE]. The DON stated LPN1 told her she had used the tuberculin syringe to administer insulin. The DON used a tuberculin syringe and an insulin syringe to calculate the actual dosage of insulin R1 had received (80 units). The DON then called the physician to tell her what happened. The DON stated she could not remember if she correctly relayed the amount of insulin administered. The doctor gave orders to check blood sugars every 30 minutes and administer glucagon if < 80 mg/dL. The DON further stated she does not remember if this was entered into the electronic medical record (EMR). The DON concluded, it was her expectation that nursing staff alert the physician if there was not necessary equipment for medication administration and for nursing staff to call the physician to clarify any orders they were uncertain of. During an interview on [DATE] at 3:52 PM, LPN2 revealed she did not take R1's blood sugars during her shift. She was only informed by LPN1 during shift change at 4:30 PM and it was not in the EMR. LPN2 stated she did not contact the physician at any point to clarify the verbal order. During an interview on [DATE] at 10:25 AM, the Chief Executive Officer (CEO) revealed he attended a care meeting regarding the incident on [DATE]. At the meeting, it was revealed that the amount of insulin the DON initially reported to the physician was not what had actually been administered. During a follow up interview on [DATE] at 12:33 PM, the MD revealed she received a call from the facility on [DATE]. She was told that R1 was given 40 or 50 units of insulin when he was ordered to receive 8 units and he was eating at that time. The MD stated she considered sending him out, but she decided to have blood sugars taken every 30 minutes and reported to her. The MD stated the facility reported blood sugars timely at first, but from 5:00 PM - 7:00 PM, she didn't receive any notifications. At about 7:00 PM or 7:30 PM, the facility notified her that his blood sugar was 49 mg/dL. The MD told them to administer glucagon. R1's blood sugar rose to 118 mg/dL. This was around 9:15 PM according to her notes, but it might have been earlier. The MD further stated she didn't hear any further notifications until about 11:00 PM when his blood sugar was 89 mg/dL. She asked if they had any more glucagon, and they did not. She asked if the resident was alert enough to drink orange juice, and he was not. The MD then ordered the resident to be sent out to the hospital. The next day, the facility informed her R1 had received 80 units of insulin instead of 40 - 50 units. The MD realized this was why his blood sugar had been so hard to control, and if she had known it was 80 units, she would have sent him to the ER straightaway. During the interview, the MD also revealed that the reason she hadn't received R1 blood sugar notifications from 5:00 PM - 7:00 PM was because LPN2, who came on shift around 5:00 PM, did not follow the verbal order for 30-minute blood sugar checks. It was only when LPN1 returned, that the facility notified her R1's blood sugar was down to 49 mg/dL. The MD stated if LPN1 had not returned, the facility would not have known to administer glucagon. The MD also confirmed that LPN2 did not contact her at any point - either to notify her of R1's blood sugars or to clarify the verbal order for fingerstick blood sugar checks every 30 minutes. On [DATE] at 10:55 AM, the facility presented a removal plan which included: R1 expired at the hospital after re-admission. There were no other residents receiving insulin at time of survey. 1:1 Education provided to LPN1 and the DON who notified the physician of R1's significant medication error using facility policies titled 1. Change in a Resident's Condition or Status and 2. Verbal Orders. Education started on [DATE] to all Licensed Staff related to Facility's policies titled 1. Change in a Resident's Condition or Status and 2. Verbal Orders. Nurses will notify resident's attending physician or the physician on call when there has been a significant change in the resident's physical/emotional/mental condition, need to alter the resident's medical treatment significantly, and need to transfer the resident to hospital/treatment center. Changes in a resident's condition or status will be communicated to on-coming and out-going nurse verbally, in writing, and recorded in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A 24-hour report in paper and 24-hour electronic documentation will be reviewed by [Interdisciplinary Team] IDT every morning during stand-up meeting for compliance and review of implemented interventions. Documentation and Compliance will be presented and reviewed monthly by the QAPI committee to inform process changes and the need for additional staff training, education, and care planning. Performance Improvement Project (PIP) will be updated monthly by IDT when needed related to additional education, training, and care plan updates for specific residents if appropriate.

Based on review of facility policy, interview and record review, the facility failed to protect 1 of 4 residents from significant medication errors. Specifically, on [DATE] at 1:19 PM, Licensed Practical Nurse (LPN)1 administered 80 units of insulin to Resident (R)1 when he was supposed to receive 8 units. This failure placed R1 at risk for serious harm and/or death due low blood sugars that could potentially cause seizures, hypoglycemic coma, or death. On [DATE] at approximately 3:00 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On [DATE] at 6:15 PM, the facility was notified that the failure to administer the prescribed dosage of insulin to R1 constituted Immediate Jeopardy (IJ) at F760. The survey team provided the facility with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.45 - Pharmacy Services. On [DATE] at 10:55 AM, the facility presented an acceptable plan of removal of the IJ. The survey team, validated the facility's due diligence to correct the noncompliance and is considering this IJ at Past Noncompliance as of [DATE]. An Extended Survey was conducted in conjunction with the Complaint Survey for non-compliance at F760, constituting substandard quality of care. Findings include: Review of the facility policy titled Adverse Consequences and Medication Errors last revised on February 2023 revealed that, a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Examples of medication errors include giving the wrong dose. A significant medication-related error is defined as requiring hospitalization , requiring treatment with prescription medication, and life-threatening. Review of the facility policy titled Subcutaneous Injections last revised on [DATE] revealed that in preparation for subcutaneous injections, staff must verify the physician's order for the medication (resident's name, drug name, dose, time, and route of administration), review the resident's care plan to assess for any special needs, and assemble the equipment and supplies as needed. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Type 2 diabetes mellitus, malignant neoplasm of head of pancreas, hepatic encephalopathy, and moderate protein-calorie malnutrition. Review of R1's Physician Orders revealed an [DATE] order for Insulin Aspart 100 units/mL qid (four times a day) - before meals and at bedtime. Cover with sliding scale. Give 2 units for ,d+[DATE] mg/dL (milligrams per deciliter). Give 4 units for 201 - 250 mg/dL. Give 6 units for ,d+[DATE] mg/dL. Give 8 units for ,d+[DATE] mg/dL. Give 10 units for 351 mg-400 mg/dL. During an interview on [DATE] at 11:46 AM, Registered Nurse (RN)1 revealed R1 was ordered for 8 units of short acting insulin but received 80. RN1 further stated, Licensed Practical Nurse (LPN)1 used the tuberculin syringe instead of the insulin syringe to calculate the dosage, believing the calibrations to be the same. The resident ate breakfast but not lunch and supper, so the doctor ordered to send the patient out to the hospital. Review of R1's late entry progress note dated [DATE] at 5:20 PM, revealed R1 received an overdose of insulin on [DATE] at 1:19 PM. At 2:00 PM, the facility contacted the Director of Nursing (DON) who contacted the Medical Director. A verbal order was given to check R1's blood sugar every 30 minutes and inject Glucagon HCL 1 mg/mL if blood sugars went below 80 mg/dL. At 3:00 PM, R1's blood sugar was 275 mg/dL. At 4:43 PM, R1's blood sugar was 163 mg/dL. At 6:45 PM, R1's blood sugar was 49 mg/dL. The Medical Director was notified and Glucagon was administered. The Medical Director advised to call back with blood sugar results in 1 hour. At 7:45 PM, R1 opened his eyes when name was called. A sternal rub was performed, and blood sugar was 118 mg/dL. The Medical Director was notified and gave another order for Glucagon administration. The Medical Director gave another verbal order to hold all insulin and check blood sugar levels at 11:00 PM and twice throughout the night. Review of LPN1's statement to the facility, written on [DATE], revealed she took R1's blood sugar at 1:15 PM, which was 343 mg/dL. According to his order, he required 8 units of insulin. She administered the insulin at 1:19 PM. At 1:59 PM she realized she had made a medication error and contacted the Director of Nursing (DON). The DON notified the doctor who ordered blood sugar checks every 30 minutes. If blood sugar is < 80, contact the doctor and administer Glucagon HCl 1 mg/mL. At 2:15 PM the resident's blood sugar was 315 mg/dL. At 2:30 PM, R1 consumed 4 oz of ginger ale. At 3:00 PM, R1's blood sugar was 275 mg/dL. At 4:43 PM, the resident's blood sugar was 163 mg/dL. At 4:45 PM, LPN1 reported the verbal order from the physician to LPN2 during shift change. That evening, around 6:45 PM, LPN1 returned to the facility to finish clerical work. LPN2 informed her she had not taken R1's blood sugars during her shift since it was not in the system. LPN1 took R1's blood sugar which was 49 mg/dL. She notified the physician and injected Glucagon 1 mg/mL. During an interview on [DATE] at 1:34 PM, LPN1 confirmed she administered insulin at 1:19 PM on [DATE] and realized the mistake at 1:59 PM. LPN1 stated she used a tuberculin syringe, not realizing it scaled differently than the insulin syringes. LPN1 stated she realized the mistake at 1:59 PM and notified the Director of Nursing (DON), who notified the physician. The physician gave the verbal order to check blood sugars every 30 minutes and contact her if the blood sugar reached 80 mg/dL and inject Glucagon. LPN1 documented blood sugars on paper and on the Electronic Medical Record (EMR). LPN1 further stated she left her shift at 4:45 PM and relayed the verbal order to the oncoming nurse (LPN2). LPN1 stated she returned to the facility at 6:45 PM and learned that LPN2 had not taken any fingerstick blood sugars in that 2-hour lapse. LPN1 stated she took the blood sugar of R1 and it was 49 mg/dL. LPN1 administered the glucagon. This was the first time that glucagon was administered to R1. During an interview on [DATE] at an unspecified time, the Medical Director (MD) revealed she was contacted by the facility at 2:00 PM on [DATE]. At that time, she was told R1 was given twice the amount of insulin ordered and his blood sugars had been in the 400s prior to administration. She was told he ate a full lunch and was eating dinner. The MD stated she did not get phone calls from approximately 5:00 PM to 7:00 PM. At around 7:00 PM she was informed R1's blood sugar was 90 mg/dL and she instructed the facility to administer glucagon. The MD stated she did not get another call for another few hours when R1's blood sugar dropped to the 70s. The MD stated she had R1 sent out to the hospital. The MD further stated, the next day the report was inconsistent with what she'd been told. R1 had received 80 units of insulin instead of 8 units, and the resident did not eat a full lunch. The MD stated if she had known this at the time it would have affected her medical decision making. She would have ordered R1 to be sent out to the ER immediately rather than conduct 30-minute blood sugar checks. The MD concluded that potential risks for a resident receiving ten times the ordered dosage of insulin included blood sugars dropping and causing seizures, unresponsiveness, hypoglycemic coma, or even death. Review of the DON's statement to the facility written on [DATE] at 6:55 PM, revealed that at 2:00 PM she received a text message from LPN1. LPN1 was at the medication cart and informed the DON that R1 had received an overdose of insulin. The DON called the Medical Director who gave telephone orders to check blood sugars every 30 minutes, notify the Medical Director with results, and administer Glucagon HCL 1 mg/mL if blood sugars are below 80 mg/dL. At 3:00 PM, R1's blood sugar was 275 mg/dL. At 4:43 PM his blood sugar was 163 mg/dL. At 6:45 PM, his blood sugar was 49 mg/dL and LPN1 administered the glucagon and notified the physician. The DON instructed LPN1 how to obtain another glucagon emergency kit in case it became necessary to administer a second dose. The Medical Director gave new orders to hold all insulin and check R1's blood sugar in another hour and inform her with results. LPN1 informed LPN2 of the new orders. LPN1 later called the DON to say another glucagon was administered and the Medical Director had been notified. The Medical Director gave new orders to check R1's blood sugars at 11:00 PM and twice during the night. At 11:42 PM, the DON contacted LPN2 for the 11:00 PM blood sugar results - which was 89 mg/dL. The Medical Director was contacted and advised to give R1 orange juice. At 1:50 AM, the DON called LPN2 and she informed the DON that R1 had been sent out to the emergency room . During an interview on [DATE] at 2:30 PM, the DON revealed she was informed of the medication error at 2:00 PM on [DATE]. The DON stated LPN1 told her she had used the tuberculin syringe to administer insulin. The DON used a tuberculin syringe and an insulin syringe to calculate the actual dosage of insulin R1 had received (80 units). The DON then called the physician to tell her what happened. The DON stated she could not remember if she correctly relayed the amount of insulin administered. The doctor gave orders to check blood sugars every 30 minutes and administer glucagon if < 80 mg/dL. The DON further stated she does not remember if this was entered into the electronic medical record (EMR). The DON concluded, it was her expectation that nursing staff alert the physician if there was not necessary equipment for medication administration and for nursing staff to call the physician to clarify any orders they were uncertain of. During an interview on [DATE] at 10:25 AM, the Chief Executive Officer (CEO) revealed that fundamentally, LPN1 failed to follow the physician order. She used the incorrect syringe to administer the insulin, resulting in administration of the incorrect dosage. During an interview on [DATE] at 12:22 PM, the Pharmacist revealed that an overdose of insulin carries the risk of serious harm or death. On [DATE] at 10:55 AM, the facility presented a removal plan which included: R1 expired at the hospital after re-admission. There were no other residents receiving insulin at time of survey. 1:1 Education provided to LPN1, monitoring of R1's blood sugars, and notification to family. Education started on [DATE] to all Licensed Staff related to Facility's policies of Administering Insulin Medication. The facility obtained skill validations and return demonstrations for all Licensed Staff how to administer Insulin per policy and Safety. All tuberculin syringes were removed from the medication cart and moved to the medication room. Insulin syringes remain available on the medication cart. Random skill validation and demonstrations of Insulin Administration among Licensed Staff will occur 2 times weekly x 6 weeks. Documentation Errors / Compliance are documented, reported, and reviewed monthly by the QAPI committee to inform process changes and the need for additional staff training. Performance Improvement Project (PIP) will be updated monthly in terms of additional education of nurses, skill validation and care plan updates for specific residents receiving insulin treatment.

Based on observation, interview, record review, and facility's policy review, the facility failed to ensure one resident (Resident (R)5) of nine sampled residents, did not self-administer her inhalant nebulizer medication without an assessment and physician's order to self-administration the medication. The facility's deficient practice increased R5's risk for adverse medication reactions. Findings include: Review of facility policy titled Self-Administration of Medication, 12/12, revealed .Residents in our facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so .As a part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications .The staff and practitioner will document their findings and the choices of residents who are potentially capable of self-administering medications . Review of the facility's policy titled Administering Medications, 12/12, revealed .Medications shall be administered in a safe and timely manner, and as prescribed . Review of R5's undated FACESHEET, located under the front cover of her chart, did not have an admitted and revealed R5's multiple diagnoses which included chronic obstructive pulmonary disease (COPD), pneumonia, and interstitial lung disease with progressive fibrotic (scarring of lung tissue) phenotype. Review of R5's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/28/23 and located on Aspen MDS Viewer revealed a Brief Interview for Mental Status (BIMS) with a score of 14 out of 15 indicating she was cognitively intact, had multiple diagnoses to include diabetes, pulmonary disease, and respiratory failure, and received oxygen therapy. Review of R5's Physician's Orders, dated 05/2023 and located in the resident's electronic medical record (EMR) under the Orders tab, revealed no order to self-administer medication. Review of R5's Medication Administration Record (MAR), dated 05/2023, located in the resident's EMR under the Orders tab, revealed no order to self-administer his medication. Review of R5's comprehensive Care Plan, located in the resident's EMR under the Care Plan tab, revealed no intervention for self-administration of medication. During an observation on 05/18/23 at 4:12 PM, Registered Nurse (RN)2 put R5's medication (Ipratropium Albuterol) solution in her reservoir cup on her nebulizer oxygen tubing, turned her nebulizer machine on and handed the mouthpiece (nebulizer oxygen tubing) to R5. RN2 exited R5's room and did not remain with R5 during her medication administration. During an observation and interview on 05/18/23 at 4:53 PM of R5 in her room sitting in her wheelchair, R5 stated she turned the nebulizer machine off. During an interview on 05/18/23 at 5:11 PM, the Director of Nursing (DON) verified R5 did not have a physician's order to self-administer her medication in her EMR. The DON stated R5's care plan did not have interventions to self-administer her medications. The DON stated a resident with the desire to self-administer their medication should be assessed to do so. The DON verified R5 did not have an assessment on her EMR to perform self-administration of her medication. The DON stated she expected the nursing staff to administer R5's medication including her nebulizer treatment, remain with R5 until the completion of her medication administration to ensure the medication administration was complete, and to monitor her for adverse reactions. During an interview on 05/18/23 at 6:02 PM, RN2 stated he did not stay with R5 for her administration of her nebulizer medication. RN2 stated he did not remain with R5 because she said she would do it. RN2 stated R5 did not have an order to self-administer her medication or a care plan intervention to self-administer her medication. RN2 stated he did not remain with R5 to monitor for side effects or ensure she took her medication, and he should have.

Based on observations, interviews, review of records, and review of facility policies, the facility failed to ensure: 1. a physician's order was obtained for blood sugar fingersticks for two residents ((R)4 and R2); and 2. R4's insulin physician's orders were correct on the Medication Administration Record (MAR) out of five residents sampled for unnecessary medications. Findings include: Review of facility's policy titled Insulin Administration, dated 09/14 and provided by the Administrator, revealed .To provide guidelines for the safe administration of insulin to residents with diabetes .The type of insulin, dosage requirements . Must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order .The nurse shall notify the Director of Nursing Services and Attending Physician of any discrepancies, before giving the insulin .Documentation .The resident's blood glucose result, as ordered . Review of facility's policy titled Obtaining a Fingerstick Glucose Level, dated 10/11 and provided by the Administrator, revealed .The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level .Verify that there is a physician's order for this procedure . 1. Review of R4's FACESHEET, undated and provided by Registered Nurse (RN)1, revealed there was no admitted for R4 and R4's had multiple diagnoses to include type 2 diabetes. Review of R4's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/04/23 located on Aspen MDS Viewer, revealed a Brief Interview for Mental Status (BIMS) with a score of 14 out of 15 indicating he was cognitively intact, had diabetes, and received insulin seven out of seven days of the lookback period of assessment. Review of R4's Physician's Orders, dated 05/2023 and under the Orders dated tab located on his electronic medical record (EMR) revealed the following: a.Lantus Solostar [class of drug-antidiabetic insulin] U [units]-100 insulin 100 units/ml [millimeter] . subcutaneous [administered under the skin] pen .-16 units Subcutaneous Twice daily inject 15 units SQ [subcutaneous] twice a day 04/29/23 . b. no order for blood sugar per fingerstick. Review of R4's PHYSICIAN PLEASE SIGN & RETURN, dated 05/09/23 under the Physician's Orders tab located on his hard chart, revealed .Increase dose of Levemir pen 100 u/ml 16 units Q AM for DM [diabetes] . indicating the insulin order was to increase the dose every morning and no order for blood sugars per finger stick. Review of R4's Medication Administration Record (MAR), dated 05/2023 and located under his Orders tab located on his EMR, revealed the following: a.Lantus Solostar U-100 Insulin 100 units/ml . 16 units subcutaneous twice daily inject 15 units twice a day 04/29/23 with staff initials indicating insulin was administered for 05/01/23-05/17/23 but failed to identify which dosage was administered in the morning (16 units) or in the evening (15 units). b.Blood Sugar 04/29/23 . with staff initials and values entered for 05/01/23-05/17/23. During an observation/record review/interview on 05/17/23 at 9:19 AM, RN1 performed blood sugar testing by fingerstick to R4 with results of 119. RN 1 administered insulin in R4's arm. RN1 verified R4 did not have an order to perform blood sugar per fingerstick on his MAR located on his EMR. RN1 verified R4's MAR revealed conflicting orders for his insulin doses with 15 and 16 units directed for his insulin injection. RN1 stated she believed R4 should be administered 16 units, but she was unsure. RN1 stated she administered 16 units of insulin to R4. RN1 stated she should have checked R4's physician's orders prior to administering his insulin. During a record review/interview on 05/17/23 at 9:42 AM, RN1 verified R4's orders on his hard chart revealed an increase in his insulin dose to 16 units. RN1 verified R4's physician's orders on his EMR revealed inconsistent dosage of his insulin with both 16 and 15 units as direction for his insulin injection twice a day. RN1 stated she would correct his physician orders on his EMR and his MAR. During a record review/interview on 05/17/23, the DON verified R4's insulin physician's orders on his EMR orders were conflicting with both doses of 16 and 15 units for injection. The DON verified R4's MAR located on his EMR had conflicting insulin doses with both 16- and 15-units injection. During an interview on 05/18/23 at 2:04 PM, the Medical Director stated she provided care for R4. The Medical Director verified R4's insulin physician's orders were inconsistent with insulin doses for both 16 and 15 units twice a day. The Medical Director verified R4 did not have a physician's order for his fingerstick blood sugar and should have one. The Medical Director stated the nursing staff should not check R4's blood sugar per fingerstick without a physician's order. 2. Review of R2's undated FACESHEET, without an admitted and provided by RN1, revealed R2's multiple diagnoses included diabetes. Review of R2's admission MDS with an ARD of 03/24/23 located on Aspen MDS Viewer, revealed a BIMS with a score of 14 out of 15 indicating he was cognitively intact and received insulin seven out of seven days in the lookback assessment period. Review of R2's Physician's Orders, dated 05/2023 and under the Orders tab located on his EMR, revealed no order for blood sugar per fingerstick. Review of R2's MAR, dated 05/2023 and under the Orders tab located on his EMR, revealed no order for blood sugar fingersticks, however blood sugar levels were entered three times a day beside his insulin dose with staff initials from 05/01/23-05/17/23 with the exception of 7:30 AM on 05/06/23 was blank. During an observation/interview on 05/18/23 at 4:27 PM, RN2 performed a blood sugar fingerstick on R2 with results of 242. RN2 verified R2 did not have a physician's order on his EMR for blood sugar per fingerstick. During an interview on 05/18/23 at 2:04, the Medical Director stated if a resident required blood sugar per fingerstick they should have a physician's order for blood sugar per fingerstick. The Medical Director stated the nurses were checking/documenting R2's blood sugars on his EMR since his admission to the facility without a physician's order.

Based on observations, interviews, records and facility policy review, the facility failed to post daily nurse staffing with facility name, date, census, and the total numbers/actual hours worked per shift for licensed and unlicensed staff responsible for resident's care in a prominent location (accessible to residents and visitors). The facility's failure increased the risk that residents and visitors would not know if there were sufficient staff for each shift to care for the residents. Findings include: Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, dated 08/2022 and provided by the Director of Nursing (DON), revealed .Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents .Within two (2) hours of the beginning of each shift, the number or licensed nurses (RN [Registered Nurse]s, LPN [Licensed Practical Nurse]s, and LVN[Licensed Vocational Nurse]s) and the number of unlicensed nursing personnel (CNA [Certified Nursing Assistant]s and NA[Nursing Assistant]s) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format .The information included on the form shall include the following: The name of the facility .The current date .The resident census .Twenty-four hour shift schedule operated by the facility .The shift for which the information is posted .Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift who are paid by the facility (including contract staff) and the Total number of licensed and non-licensed nursing staff working for the posted shift . During the initial tour on 05/16/23 at 10:08 AM there was no daily staffing posted in the facility (foyer or on the resident's unit). During a second observation on 05/17/23 at 11:08 AM there was no daily staffing posted in the facility (foyer or on the resident's unit). During the third observation on 05/18/23 at 9:10 AM there was no daily staffing posted in the facility (foyer or on the resident's unit). During an interview on 05/18/23 at 10:01 AM, the DON stated the facility did not post the daily staffing on the wall or display at the facility but kept it in a binder at the nurses' desk. The DON stated she could not find the daily staffing in the binder at the nurses' desk. The DON stated the Scheduling Coordinator (SC) had the daily staffing documents. During an interview on 05/18/23 at 10:05 AM, the SC stated he was responsible for updating the daily staffing sheet and he ensured there was enough staff according to the facility census. The SC stated the facility did not post/display the daily staffing document. The SC stated he did not post/display the daily staffing document at the facility and if the facility required the document to be posted/displayed it would be his responsibility to ensure it was posted.

Based on observation, record review, policy review, and interview, the facility failed to ensure Care Plans were developed and implemented for 2 out of 3 residents reviewed for hospitalization s (Residents 5 and 9). The findings include the following: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 5's medical record on 08/28/19 at 12:45 PM revealed s/he was sent to the hospital on [DATE] following an incident of drooling, fixed eye gaze, and inability to grasp a hand. Resident #5 returned from the hospital on [DATE] with an increase in the medication [MEDICATION NAME] to address [MEDICAL CONDITION] activity. Review of Resident #5's initial Care Plan on 08/28/19 at 12:50 PM revealed the Care Plan listed falls as a risk and included [MEDICAL CONDITION] as a potential risk to increase falls, but the Care Plan did not directly address Resident #5's [MEDICAL CONDITION] history including type of [MEDICAL CONDITION], frequency of [MEDICAL CONDITION], or [MEDICAL CONDITION] medications and no revisions or additions had been made to the Care Plan following Resident #5's 07/18/19 hospitalization related to [MEDICAL CONDITION] activity. During an interview on 08/28/19 at approximately 1:00 PM, the Facility Administrator confirmed that Resident #5 was admitted to the facility with a [DIAGNOSES REDACTED].#5 was receiving [MEDICAL CONDITION] medication and this medication was increased following Resident #5's 07/18/19 hospitalization . The Facility Administrator confirmed Resident #5's Care Plan should have been revised following the hospitalization to address the [MEDICAL CONDITION] disorder and related medication. Resident #9 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's 8/14/19 Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of 14. During the initial pool process and initial facility rounds, Resident #9 was observed in her/his wheelchair on 08/25/2019 at approximately 01:45 PM. Resident #9 informed the surveyor that her/his right foot and ankle hurt and that no one had looked at her/his right foot. Resident #9 stated I have told everybody. The Surveyor reported the concern to Licensed Practical Nurse (LPN) #1. LPN #1 verified that Resident #9 had a pressure ulcer to her/his right ankle unidentified by the facility staff and not treated or assessed until the surveyor brought it to the facility LPN's attention based on the concern by Resident #9. Record review on 8/25/19 at 02:30 PM with LPN #1 of Resident #9's medical record revealed that the facility last performed a documented body audit for Resident #9 on 8/2/19. This finding was confirmed by LPN #1. The 8/2/19 body audit revealed that Resident #9's skin was documented as intact with old venipuncture site on the right and left forearm. LPN #1 confirmed that no treatment orders were in place for Resident #9's Stage 2 pressure ulcer of the right outer ankle. Review of Resident #9's medical record revealed a note dated 8/25/19 at 8:45 PM that the Doctor was notified of open area to right outer ankle. Resident #9's Weekly Pressure Ulcer Record dated 08/25/2019 revealed right outer ankle identified as a Stage 2 measuring 0.5 x 0.5 x 01 and treatment order was initiated to clean the area with normal saline, apply a polymem oval dressing every 3 days and as needed. Review of the facility Skin Care Protocol Policy and Procedure #2 under procedures the policy states, Weekly skin assessment to be completed and documented on the Body Audit form for all residents. Review of Resident #9's medical record revealed a care plan which included concerns about the resident's abdominal folds redness. Interventions were to assess the resident's skin weekly.

Based on interviews, observations, medical record review and review of the facility Skin Care Protocol Policy the facility failed to perform weekly skin assessments to identify and treat a pressure ulcer for Resident #9. The findings include the following: Resident #9 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During the initial pool process and initial facility rounds, Resident #9 was observed in her/his wheelchair on 08/25/2019 at approximately 01:45 PM. Resident #9 informed the surveyor that her/his right foot and ankle hurt and that no one had looked at her/his right foot. Resident #9 stated I have told everybody. The Surveyor reported the concern to Licensed Practical Nurse (LPN) #1. LPN #1 verified that Resident #9 had a pressure ulcer to her/his right ankle unidentified by the facility staff and not treated or assessed until the surveyor brought it to the facility LPN's attention based on the concern by Resident #9. Record review on 8/25/19 at 02:30 PM with LPN #1 of Resident #9's medical record revealed that the facility last performed a documented body audit for Resident #9 on 8/2/19. This finding was confirmed by LPN #1. The 8/2/19 body audit revealed that Resident #9's skin was documented as intact with old venipuncture site on the right and left forearm. LPN #1 confirmed that no treatment orders were in place for Resident #9's Stage 2 pressure ulcer of the right outer ankle. Review of Resident #9's medical record revealed a note dated 8/25/19 at 8:45 PM that the Doctor was notified of open area to right outer ankle. Resident #9's Weekly Pressure Ulcer Record dated 08/25/2019 revealed right outer ankle identified as a Stage 2 measuring 0.5 x 0.5 x 01 and treatment order was initiated to clean the area with normal saline, apply a polymem oval dressing every 3 days and as needed. Review of the facility Skin Care Protocol Policy and Procedure #2 under procedures the policy states, Weekly skin assessment to be completed and documented on the Body Audit form for all residents.

Based on observation, policy review, and interview, the facility failed to ensure medications were stored in a secure manner for 1 out of 6 residents reviewed for accidents (Resident 19). The findings are: Resident #19 was admitted to the facility on [DATE]. Review of Resident #19's 8/26/19 Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of 15. Observation in Resident #19's room on 08/25/19 at 02:09 PM revealed medication bottles which included [MEDICATION NAME] 10,00 mcg (3/4 bottle), Garlique OTC (opened in a box/labeled), Calcium 600 plus D3 OTC (3/4 bottle full), and [MEDICATION NAME] Silver Vitamins (3/4 bottle) in clear sight sitting on the resident's bedside table. Registered Nurse #1 went into the room with the surveyor, s/he confirmed the medications were present and in full view and removed the medications to a secure location. During an interview on 08/26/19 at 1:45 PM, Resident #19 confirmed s/he was administering her/his own [MEDICATION NAME], Garlique, Calcium, and [MEDICATION NAME] before it was removed from his/her room. Review of the facility policy titled Medications, Self-Administration of Drugs revealed residents were allowed to self-administer medications if there was a physician's order to self-administer medications and if the medications were stored in a closed drawer at the bedside. During an interview on 08/28/19 at 11:18 AM, the Facility Administrator confirmed Resident #19 did not have an order to self-administer medications and should not have the medications in his/her room.

Based on observation, interview and review of the facility policy titled, Proper Thawing, the facility failed to follow a procedure to ensure meat was thawed properly during meal preparation in 1 of 1 kitchen with the potential for affect all residents eating food prepared in the kitchen. The findings included: An observation during initial tour of the kitchen on 11/19/2018 at approximately 8:45 AM revealed meat thawing in a sink of water. The water was not running over the meat. An interview on 11/19/2018 at approximately 8:45 AM with the Culinary Production Manager confirmed the findings and stated, the water should have been running over the meat. Review on 11/21/2018 at approximately 9:15 AM of the facility policy titled, Proper Thawing, states under Policy: All frozen foods will be thawed according to proper thawing methods. The Purpose: states, Proper thawing methods help minimize the time food is in the temperature danger zone and prevent cross-contamination. The Procedure under #1 states, There are four safe ways to thaw frozen foods. The second bullet states, Cold running, potable water may be used if the the product can be thawed in 2 hours or less. The water should be 70 degrees or below. In order to prevent cross contamination do not mix different products in the sink to thaw at the same time. The sink should be cleaned and sanitized before and after thawing each item.

Based on observation, interviews and review of the facility policy titled, Dryer Lint Policy, and Policies and Procedures for Handling Soiled Linen, the facility failed to ensure an excessive amount of lint was removed from 2 of 2 clothes dryers. The findings included: An observation on 11/19/2018 at approximately 8:45 AM of the laundry room revealed 2 of 2 clothes dryers with an excessive amount of lint build-up on the upper 3 inside walls and hanging on the wiring. An interview on 11/19/2018 at approximately 8:50 AM with the laundry worker confirmed the excessive build up of lint in the clothes dryers. A second interview on 11.19/2018 at approximately 9:30 AM with the Housekeeping Supervisor confirmed the excessive lint build up and provided the facility policy on lint removal. Review on 11/19/2018 at approximately 9:45 AM of the facility policy titled, Dryer Lint Policy, states, Remove lint from the dryer lint screen every time you use the dryer. This helps prevent a fire, but it also helps laundry to dry faster. Review on 11/19/2018 at approximately 9:45 AM of the facility policy titled, Policy And Procedure For Handling Soiled Linen, number 5 states, All lint in dryer vents needs to be cleaned after every load dried. It is important that is is done to prevent fires in the dryer. No documentation could be found to ensure the area behind the lint baskets were cleaned on a regular basis.

Based on record review, interview and review of the facility policy titled, Influenza Vaccine, and Pneumococcal Vaccine, the facility failed to ensure Resident #122 was afforded the right to make his/her own decisions to receive or decline the Influenza Vaccine and the Pneumococcal Vaccine for 1 of 5 residents reviewed for the Influenza Vaccine and the Pneumococcal Vaccine. The Findings included: The facility admitted Resident #122 with [DIAGNOSES REDACTED]. Review on 11/20/2018 at approximately 12:30 PM of the medical record for Resident #122 revealed forms titled, Resident Vaccine Acceptance or Declination of the Influenza Vaccine and Resident Vaccine Acceptance or Declination of the Pneumococcal Vaccine. Both forms were signed by the Personal Representative. No documentation could be found in the medical record to ensure Resident #122 was deemed unable to make her own health care decisions by 2 physicians. Review on 11/20/2018 at approximately 1:00 PM of the facility policy titled, Influenza Vaccine, states under Policy: All residents, volunteers, private duty sitters and employees who have direct contact with residents will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. Further review on 11/20/2018 at approximately 1:00 PM of the facility policy titled, Pneumococcal Vaccine, states under Policy: All residents will be offered the Pneumovac (Pneumococcal Vaccine) to aid in preventing pneumococcal infections (e.g., Pneumonia) An interview on 11/20/2018 at approximately 1:40 PM with the Administrator confirmed that Resident #122 was not offered the Flu and Pneumonia Vaccine, but the personal representative had declined for Resident #122 to receive them.

Based on record review, interview and review of the facility policy titled, Advance Directive Use, the facility failed to ensure Resident #122, #13 and #1 were afforded the right to formulate an advance directive for 3 of 3 residents reviewed for Advance Directives. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review on 11/19/2018 at approximately 2:08 PM of the medical record for Resident #1, revealed a form titled, Resuscitation Status Consent Form, signed by Resident #1's personal representative. Resident #1 has a BIMS (Brief Interview for Mental Status) score of 15 out of 15. Resident #1 was not deemed unable to make his her own health care decisions for 2 physicians and therefore could formulate his/her own Advance Directive and sign for his/her wishes. The facility admitted Resident #122 with [DIAGNOSES REDACTED]. Review on 11/19/2018 at approximately 5:07 PM of the medical record for Resident #122 revealed a form titled, Resuscitation Status Consent Form, singed by Resident #122's personal representative. Resident #122 was not deemed unable to make his/her own health care decisions by 2 physicians and therefore could make the decision to be Full Code Status or a Do Not Resuscitate Status. The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Review on 11/20/2018 at approximately 11:08 AM of the medical record for Resident #13 revealed a form titled, Resuscitation Status Consent Form, signed by Resident #13's personal representative. Resident #13 has a BIMS of 15 out of 15, and was not deemed unable to make his her own health care decisions by 2 physicians and therefore could make his/her own decisions related to Code Status. An interview on 11/20/2018 at approximately 11:10 AM with the Administrator confirmed that Resident #1, #122 and #13 were able to make his/her own decision to formulate an Advance Directive and were not deemed unable to make his?her own health care decisions by 2 physicians. Review on 11/20/2018 at approximately 12:35 PM of the facility policy titled, Advanced Directive Use, which states, It is the policy of the facility to comply with state and federal regulations to provide each resident or responsible party, upon admission, a copy of the facility's policy regarding the implementation of the Patient Self-Determination Act which explains resident's rights under the law to make decisions regarding their health care.

Based on record review and interview the facility failed to ensure Resident #13 and the personal representative received in writing and in a language they could understand of the the reason for the transfer to the hospital for 1 of 1 resident reviewed for hospitalization . The findings included: The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Review on 11/20/2018 at approximately 12:10 PM of the medical record for Resident #13 revealed Resident #13 was transferred to the hospital on [DATE]. A transfer form was found in the medical record but no documentation to ensure the resident and the personal representative had received in writing and in a language they could understand of the reason for transfer to the hospital. During an interview on 11/21/2018 at approximately 9:30 AM with the Administrator confirmed that a copy of the Resident Transfer Form had gone in the packet to the hospital during the transfer but Resident #13 and the Personal Representative had not received a copy.

Based on record review, interview and review of the facility's, Admission Agreement, the facility failed to ensure Resident #13 and or his/her personal representative received a copy of the Bed Hold Policy with the bed payment upon transfer/discharge to the hospital for 1 of 1 resident reviewed for hospitalization . The findings included: The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Review on 11/20/2018 at approximately 12/15 PM of the medical record for Resident #13 revealed this resident nor the personal representative have received a copy of the bed hold policy with the bed payment. An interview on 11/21/2018 at approximately 9:40 AM with the Administrator confirmed that Resident #13 nor the personal representative had received a copy of the Bed Hold Policy with the bed payment upon transfer to the hospital. The Administrator stated, The personal representative did not want to hold the bed. Review on 11/21/2018 at approximately 10:00 AM of the facility's, Admission Agreement. states, In the event that a resident is eligible for Medicare Part A benefits and is transferred to or readmitted to a hospital, Medicare Part A eligibility will be determined on the day the resident is admitted to the hospital. Resident's bed will be reserved at the Routine Services Daily Rate unless the resident elects, in writing, not to reserve a bed. During an interview on 11/ 8 at approximately 10:00 AM, the Social Service Worker stated, It is in our Admission Agreement, that the Resident nor the personal representative receives a copy of the Bed Hold Policy unless they are admitted to the hospital. If they go out to the hospital and then return because they are not admitted they do not receive a copy of the Bed Hold Policy with the bed payment.